Luận án: Luật Cần sa Y tế, Bảo hiểm Y tế và Sử dụng Chăm sóc Sức khỏe - Nghiên cứu của Pelin Ozluk tại Đại học Georgia

Georgia State University ScholarWorks @ Georgia State University Economics Dissertations 12-11-2018 Essays on Medical Marijuana Laws, Health Insurance and Health Care Utilization Pelin Ozluk Follow this and additional works at: https://scholarworks.edu/econ_diss Recommended Citation Ozluk, Pelin, "Essays on Medical Marijuana Laws, Health Insurance and Health Care Utilization." Dissertation, Georgia State University, 2018.edu/econ_diss/148 This Dissertation is brought to you for free and open access by ScholarWorks @ Georgia State University. It has been accepted for inclusion in Economics Dissertations by an authorized administrator of ScholarWorks @ Georgia State University. For more information, please contact scholarworks@gsu. ABSTRACT ESSAYS ON MEDICAL MARIJUANA LAWS, HEALTH INSURANCE AND HEALTH CARE UTILIZATION BY PELIN ÖZLÜK AUGUST 2018 Committee Chair: Charles Courtemanche Major Department: Economics National Health Expenditures Accounts estimates that U.S health care spending grew 4.3 percent from the previous year to reach $3.3 trillion, or $10,338 per person in 2016.

The overall share of gross domestic product (GDP) related to health care spending was 17.9 percent in 2016, up from 17. Moreover, increased use of opioid prescriptions led to excessive use and abuse of these drugs, resulting in nationwide “opioid epidemic”. This dissertation examines how different policy interventions contributed to the rise in health care utilization and prescribed opioids in U. The first chapter examines how medical marijuana laws changed utilization of prescription drugs with a special emphasis on prescribed opioids.

More than half of the US population lives in a state that has adopted medical marijuana laws (MMLs). Studies show that most medical marijuana patients use marijuana for managing their pain with the overwhelming majority of them preferring it to opioids. Despite ongoing pro-marijuana policies and the growing trend of public acceptance, the evidence on how people change their prescription use due to the availability of marijuana as an alternative treatment is limited. Using the variations across state MMLs between 1996 and 2014 of Medical Expenditure Panel Survey (MEPS) this paper estimates the effects of MMLs on prescription drug utilization, with a focus on opioids.

I find that MMLs lead to a $2.47 decrease in per person prescribed opioid spending among young adults (ages 18-39) over a year. Most of this decrease results from the intensive margin of use and MML states that allow home cultivation experience even larger decreases. Furthermore, the decreasing effects are persistent over time and they get stronger following the years of implementation. MMLs also decrease the number of opioid pill use among young adults.

I do not find any discernible impact on older populations' opioid utilization. I then investigate the effects on other prescriptions for which marijuana can be a potential substitute and find the allowance of dispensaries is generally associated with decreases, although the effects depend on the type of MML, the margin of use and age. The second chapter examines how universal insurance coverage affects health care utiliza- tion drawing evidence from the health reform of Massachusetts in 2006. This law reformed insurance markets, mandated that all residents in the state would be required to take up health insurance, and provided subsidies for lower-income individuals to purchase it.

Using data from MEPS between 2000 and 2015, I provide evidence that the Massachusetts health care reform increased counts of hospital and office-based medical provider visits significantly. The results were robust to using alternative control groups and different functional form as- sumptions. I find the reform's effects grew over time, reaching its maximum after 2010. The reform also increased health care expenditures and probability of health care service use significantly.

Finally, I use the reform to instrument for health insurance and estimate large impacts of insurance on health care utilization. The third chapter examines the impact of the Affordable Care Act on health care uti- lization. The Affordable Care Act (ACA) aimed to achieve nearly universal health insurance coverage in the United States through a combination of regulations, mandates, subsidies, exchanges, and Medicaid expansions. We use data from the Medical Expenditure Panel Survey (MEPS) to investigate the impacts of the ACA on the health care utilization and ex- penditures of non-elderly adults.

A difference-in-difference-in-differences strategy separately identifies the effects of the ACA's expansions of private and Medicaid coverage by leveraging variation in states' Medicaid expansion decisions and individuals' pre-ACA insurance status. Intuitively, impacts of the ACA's insurance expansions should be concentrated among those who lacked insurance prior to the law, and such individuals are more likely to be affected in states that participated in the Medicaid expansion. Similar methods have been used to study the ACA's effects on outcomes such as health insurance coverage, access to care, risky health behaviors, and self-assessed health. However, they have not been previously used to investigate impacts on health care spending.

Theoretically, the net effect on spending is ambiguous. On one hand, insurance lowers the effective price of care, which should increase utilization across-the-board. On the other hand, insurance improves access to primary and preventive care, which could potentially reduce use of expensive emergency services. The results suggest that the ACA increased health care utilization in some dimensions – in- cluding counts of inpatient hospital visits, medical-provider office visits and total counts of prescription fills, inpatient, outpatient, medical-provider office and ER visits combined on its first year.

However, these increases in health care utilization in counts were not observed in ACA's second year. We also found that the ACA increased coverage and led to significant gains in both expansion and non-expansion states consistent with what has been found by prior studies. This significant gain in insurance was not limited to ACA's first year but it carried to second year. ESSAYS ON MEDICAL MARIJUANA LAWS, HEALTH INSURANCE AND HEALTH CARE UTILIZATION BY PELIN ÖZLÜK A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy in the Andrew Young School of Policy Studies of Georgia State University GEORGIA STATE UNIVERSITY 2018 Copyright by Pelin Özlük 2018 ACCEPTANCE This dissertation was prepared under the direction of Pelin Özlük’s Dissertation Committee.

It has been approved and accepted by all members of that committee, and it has been accepted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Economics in the Andrew Young School of Policy Studies of Georgia State University. Dissertation Chair: Charles Courtemanche Committee: James Marton Shiferaw Gurmu Jason Hockenberry Electronic Version Approved: Sally Wallace, Dean Andrew Young School of Policy Studies Georgia State University August, 2018 DEDICATION This dissertation is dedicated to my grandmother, Ayşe Dinç. iv ACKNOWLEDGMENTS I would like to express my deepest appreciation to my advisor, Chuck Courtemanche for guiding and supporting me over the years. Without his guidance this dissertation would not have been possible.

He has set an excellent example of a mentor, and role model for me. I would also express my gratitude to my dissertation committee members Jim Marton, Shif Gurmu and Jason Hockenberry for all of their guidance through this process; their discussion, ideas, and feedback have been invaluable. I would also like to thank Tom Mroz for always being available to discuss and guide my research, and Garth Heutel for his support. I am extremely grateful to my mom, Vicdan Dinç for her endless love, support and protection.

I would not have been who I am without her by my side. I am deeply grateful to my sister, Ekin Özlük for being my best friend and my guide in life. I am incredibly lucky to have her as my sister. I would also extend my deepest gratitude to my brother in law Jason Neymeyer who has been an excellent role model and my support system for me over the years.

I also owe many thanks to my father Kenan Özlük for always being on my side. I would like to extend my thanks to my best friends in life, Lale Seçginli and Aylin Kertik for their endless love and friendship. I am very grateful to have met you earlier in life so I could grow with you. I am deeply thankful to all the other great friends I have made in the program.

They have been incredibly supportive and made my experience at Georgia State fun. I want to specifically thank Rhita Simorangkir for her genuine friendship. Last but not least, I would like to express my gratitude to Kuzu, Koko, Buck and Teddy for filling my life with love and fun. v Table of Contents ACKNOWLEDGMENTS v List of Figures viii List of Tables ix Chapter 1 :The Effects of Medical Marijuana Laws on Utilization of Pre- scribed Opioids and Other Prescription Drugs 1 1.1 Medical uses of marijuana and substitutability with opioids .2 Effects of MMLs and contribution of this study .1 Data characteristics and two-part model .2 Effects on total number of opioid pills .3 Effects on the utilization of other prescription drugs.

27 Chapter 2 :The Impact of Universal Coverage on Health Care Utilization: Evidence from Massachusetts 29 2.2 Tests Related to Inference. 46 Chapter 3 :The Impact of the Affordable Care Act on Health Care Utiliza- tion 48 3.1 Effects of Health Insurance on Health Care Utilization .2 Effects of the 2014 Affordable Care Act .5 Sensitivity and Other Checks. 65 Appendix 103 References 112 VITA 121 vii List of Figures 1.1 Distribution of opioid expenditures - Ages 18+ .2 Results from event study analyses on opioid expenditures .1 Changes in Health Care Service Use Counts 2000 to 2015 .2 Changes in Health Care Service Use Spending 2000 to 2015. 69 viii List of Tables 1.1 Medical marijuana laws and provisions by state, 1996-2014 .2 Summary statistics for outcome variables .3 Summary statistics for control variables .4 Ages 18-39 - Average marginal effects on opioid spending .5 Ages 40-64 - Average marginal effects on opioid spending .6 Ages 65+ - Average marginal effects on opioid spending .7 Effects of different policy combinations on opioid expenditures .8 Average marginal effects on opioid pills .9 Other medicines Ages 18-39 .10 Other medicines Ages 40-64 .11 Other medicines Ages 65+ .12 Placebo Test Ages 18-39 .13 Placebo Test Ages 40-64 .14 Placebo Test Ages 65+ .1 Means of control variables .2 Means of outcome variables .3 Effects of the reform on health care utilization of counts: Average marginal effects from negative binomial .4 Effects of the reform on health care utilization of counts: Average marginal effects from hurdle model .5 Effects of the reform on health care utilization on spending: Average marginal effects from two-part model .6 Effects of the reform on health care utilization on the extensive margin: Av- erage marginal effects from probit .7 Effects of the reform on health care utilization on the intensive margin: Av- erage marginal effects from GLM .8 Match on pretreatment levels: Average marginal effects from negative binomial 86 2.9 Match on pretreatment trends: Average marginal effects from negative binomial 87 2.10 Match on pretreatment coverage: Average marginal effects from negative bi- nomial .11 New England states: Average marginal effects from negative binomial .12 Synthetic control group: Average marginal effects from negative binomial .13 Event study: Average marginal effects from negative binomial .1 Summary statistics for outcome variables for all the samples .2 Summary statistics for control variables .3 Effects of ACA on probability of having insurance coverage: LPM results .4 Effects of ACA on health care utilization of counts between 2013-2014: Aver- age marginal effects from negative binomial .5 Effects of ACA on health care utilization of counts between 2014-2015: Aver- age marginal effects from negative binomial .6 Effects of ACA on health care Utilization of Counts Between 2013-2014: Av- erage marginal effects from poisson .7 Effects of ACA on health care utilization of counts between 2014-2015: Aver- age marginal effects from poisson .8 Effect of ACA on health care expenditures 2013-2014: Average marginal ef- fects from two-part model (First part: Probit, Second part: GLM with a log link and gamma family) .9 Effect of ACA on probability of health care utilization 2013-2014: Average marginal effects from probit model .